Anesthesiology Residency Questions

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TempleChairman

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I currently serve as the Chair of the Department of Anesthesiology at Temple University in Philadelphia. I was recently referred to this forum by one of our residents. It was their feeling that there was an unmet need for well informed information amongst medical students applying to the specialty, residents struggling to understand their purpose of their training programs, and new graduates trying to determine what direction to take their career.

Although I can also be contacted directly through the university, I understand that many may feel more comfortable with the anonymity afforded by the SDN.

That said, if anyone has questions they would like to post, I will do my best to break away from my day job to provide whatever guidance I can.

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I currently serve as the Chair of the Department of Anesthesiology at Temple University in Philadelphia. I was recently referred to this forum by one of our residents. It was their feeling that there was an unmet need for well informed information amongst medical students applying to the specialty, residents struggling to understand their purpose of their training programs, and new graduates trying to determine what direction to take their career.

Although I can also be contacted directly through the university, I understand that many may feel more comfortable with the anonymity afforded by the SDN.

That said, if anyone has questions they would like to post, I will do my best to break away from my day job to provide whatever guidance I can.

Very kind of you to post here and provide feedback to the students.
 
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I currently serve as the Chair of the Department of Anesthesiology at Temple University in Philadelphia. I was recently referred to this forum by one of our residents. It was their feeling that there was an unmet need for well informed information amongst medical students applying to the specialty, residents struggling to understand their purpose of their training programs, and new graduates trying to determine what direction to take their career.

Although I can also be contacted directly through the university, I understand that many may feel more comfortable with the anonymity afforded by the SDN.

That said, if anyone has questions they would like to post, I will do my best to break away from my day job to provide whatever guidance I can.
Thanks for doing this, TempleChairman. What's your feeling about US citizens who did med school overseas in Australia or New Zealand (due to family living there, not because of rejections or any other red flags or anything like that from US med schools), and are otherwise solid candidates? Basically just wondering what you think about (US) IMGs from similarly developed nations? Thanks again, sir.
 
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Thanks for the offer of guidance.

I'd imagine it gets tiring hearing the same questions from interviewees, over and over. What are some questions that you have been asked over the years, that stand out (in a good way)?
 
I currently serve as the Chair of the Department of Anesthesiology at Temple University in Philadelphia. I was recently referred to this forum by one of our residents. It was their feeling that there was an unmet need for well informed information amongst medical students applying to the specialty, residents struggling to understand their purpose of their training programs, and new graduates trying to determine what direction to take their career.

Although I can also be contacted directly through the university, I understand that many may feel more comfortable with the anonymity afforded by the SDN.

That said, if anyone has questions they would like to post, I will do my best to break away from my day job to provide whatever guidance I can.

Thank you Chairman for providing this opportunity. Overall, there seems to be a lot of concern about where our specialty is headed, especially the private practice sector. Even though some academic jobs might provide greater satisfaction, the huge difference in pay scale, and insurmountable student debt force many new grads to make financially motivated decisions. How are you advising your graduating residents? And how do you see the future?
 
Thanks for doing this, TempleChairman. What's your feeling about US citizens who did med school overseas in Australia or New Zealand (due to family living there, not because of rejections or any other red flags or anything like that from US med schools), and are otherwise solid candidates? Basically just wondering what you think about (US) IMGs from similarly developed nations? Thanks again, sir.

Hi bashwell, I should probably preface everything else I will post on this site by noting that I am one individual, representing one US residency program, and can not (unless otherwise noted) relate overall policies or practices for the US training system as a whole.

That said, at Temple we have a few basic screening criteria when reviewing applicant files. The applicant must have attended a medical school acceptable to the ACGME (domestic or foreign) and must have passed the USMLE step one. Without exaggeration, after those criteria are met everything else is “on the table”.

We (the faculty) have spent considerable time and effort identifying the commonalities amongst past residents that have excelled, and those that have failed to complete the program or have just barely made it through. I will not lead you through the exhaustive arguments here but I can summarize by saying that we are actively seeking those individuals who come to residency training with a breadth and depth of life experiences and have elements in their past that suggest they both strong analytical skills, personal discipline, and grit.

I have seen some extensive discussions on this board as I considered starting a thread about required USMLE scores. I will state that these are somewhat misguided conversations. Although there are a few programs around the country where these scores compose a significant component of the screening or matching process, I believe they are in the minority. Certainly at Temple we will actively pursue a candidate with a lower range USMLE score who has exceptional personal characteristics. And there are individuals who score highly on the USMLE who we will not rank simply because we are not convinced they have the characteristics required to succeed in our particular specialty.

So, the pointed answer to your question is: foreign medical training by itself is (in my view) usually not a factor one way or the other in our selection process and the same probably applies to many other programs.

Hope this helps.
 
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Thanks for the offer of guidance.

I'd imagine it gets tiring hearing the same questions from interviewees, over and over. What are some questions that you have been asked over the years, that stand out (in a good way)?

Hi sts84,

I think the two most common questions I am asked are about the requisites to obtain a residency spot (see answer to bashwell above) or about the future of the specialty (see mostwanted below).

I think the most insightful questions (i.e.: most helpful for the medical student) usually involve the themes of what I like most about the specialty (working in a team environment, very performance based, immediate feedback on decisions, very intense patient interactions - you really have their attention when you are preparing to anesthetize them) or what I like least about the specialty (you do not control your own schedule and the hours can be long and grueling).
 
Thank you Chairman for providing this opportunity. Overall, there seems to be a lot of concern about where our specialty is headed, especially the private practice sector. Even though some academic jobs might provide greater satisfaction, the huge difference in pay scale, and insurmountable student debt force many new grads to make financially motivated decisions. How are you advising your graduating residents? And how do you see the future?

Mostwanted, I think there are two aspects to this question that I will attempt to answer separately: the future of the specialty and the dichotomous decision of academic versus private practice.

Regarding the future of the specialty, I think this is an understandable but misplaced concern. If you define “Anesthesiology” simply as the placement and removal of endotracheal tubes and the administration of sedatives / analgesics / anesthetics you might have some reason for apprehension. The administration of anesthesia is undeniably now safer than it was throughout most of the 20th century. This should allow more operating room care to be provided by a single anesthesiologist (through the expanded use of midlevel providers) or for more care to be provided in non-OR locations.

However, the facts on the ground are that the improvements in anesthetic care are pushing proceduralists to request our assistance with an ever expanding number of progressively more impaired patients. This is rapidly expanding the patients for whom our assistance is needed. At the same time, the push towards “perfect performance” (i.e.: zero complications or delays) and improved patient satisfaction is making overall management of the systems in which we participate more and more complex.

The demands on our faculty to provide care in more areas of the hospital, in more ways (acute pain service, critical care, perioperative echocardiography or ultrasound diagnosis, care pathway development, “prehabilitation”, overall quality control and improvement) than ever before is constantly taxing our capacities. Many of these functions are completely beyond the scope of practice of our midlevel colleagues and can only be performed by our physician staff.

I have heard this argument before (“the future is bleak for anesthesiologists”), most notably in the 1990’s. The prediction proved completely incorrect at that time and I expect that the same will apply this time.

With regard to private practice versus academics, the difference is probably not as distinct as you might imagine. Although it is very dependent on the region of the country under discussion, as a general statement the spread between salaries in private practice and academics has decreased significantly during the past decade. In addition, even in private practices the push to integrate more fully into institutional management structures is considerable (for the reasons noted above). It is my firm belief that the next ten years will see a rapid shift to institutional employment of most hospital based specialties (anesthesiology, radiology, emergency medicine, many surgical disciplines). This will be driven by the major shift, already underway, away from fee for service and towards bundled or episodic payments. Once an institution receives a single payment for all costs associated with a procedure or admission there is a compelling argument to have all of the associated players working under a common management structure which frees them to act truly in the patient’s best interest rather than pursue each of their own individual best interests.

Once most practices become institutionally based the distinction between academic versus non-acedmic practice will actually be limited mainly to the desire to teach and / or conduct research or other scholarly work, or simply participate in clinical operations . If you are now, or are soon to be, entering practice this is the main decision I think you will face.
 
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Thank you Chairman for your insight. Piggybacking on your post regarding the future of the specialty, what do you think of the Perioperative Surgical Home initiative and renaming the specialty "Perioperative Medicine?"

Also, one major topic that has been discussed on this forum many times by Attendings is the downward trend of salaries for anesthesiologists and sharp decline in the number of job opportunities for new graduates. Obviously, salaries are not the most important factor in selecting a specialty, but for many students with excess loans (especially those who started medical school at a later age), the stability and compensation of a specialty does a play role in the decision. I would be curious and grateful to read your thoughts on where salaries for anesthesiologists are headed in the future.
 
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Thank you Chairman for your insight. Piggybacking on your post regarding the future of the specialty, what do you think of the Perioperative Surgical Home initiative and renaming the specialty "Perioperative Medicine?"

Also, one major topic that has been discussed on this forum many times by Attendings is the downward trend of salaries for anesthesiologists and sharp decline in the number of job opportunities for new graduates. Obviously, salaries are not the most important factor in selecting a specialty, but for many students with excess loans (especially those who started medical school at a later age), the stability and compensation of a specialty does a play role in the decision. I would be curious and grateful to read your thoughts on where salaries for anesthesiologists are headed in the future.



Carbocation, I think the concepts encompassed by the terms Perioperative Surgical Home and Perioperative Medicine are exactly where the speciality of anesthesiology is heading. I do understand why the leaders of our specialty are promoting these terms in an attempt to disseminate the foundational principles amongst the 35,000 or so anesthesiologists across the country.

However, you should also understand that these terms have some political baggage attached to them as the result of the last 4 decades of “turf wars” that occurred in the US medical community. In the world of fee-for-service medicine the specialty that could “lay claim” to the most procedures or the greatest scope of expert opinion stood to gain financially. Thus, when the anesthesiology community promotes the idea of the Perioperative Surgical Home, there are both surgeons and internists that feel threatened by this and we have indeed seen negative commentary by the leadership of other specialty societies.

However, such feelings are misguided. I think the terms Perioperative Surgical Home and Perioperative Medicine both describe an organizational process that will provide the optimal care and overall experience from the patient perspective, rather than a new subspecialty of anesthesiology. This organizational process will be a team effort involving physicians and midlevel providers from various disciplines. The composition of these teams will vary from institution to institution. In many instances the team leadership will come from an anesthesiologist, but in every instance anesthesiologists who understand the organizational principals will need to be integrally involved.

As for salaries, predicting who will make what sort of income at some point in the future is very difficult. However, I think there are some generalities that can be applied.

During the past 30 years there were certain physicians who managed to generate enormous incomes as a result of what can be described as “multiplier effects”. It is difficult under a fee-for-service system for any single physician to generate enough work to provide a personal net income of $600,000 as an anesthesiologist, or $1,000,000 as an orthopedic surgeon. However, by employing many other providers (CRNAs, non-partner anesthesiologists) or by providing a large volume of profitable business to an institution with deep pockets (large numbers of inpatient admissions for a hospital) there were many specialists who did reach these income levels.

In the future, as hospital based specialties convert more and more to institutional employment, and as patients become clients of hospitals or health systems rather than individual “superstar” specialists, the opportunity to harvest these multiplier effects will dry up. The net effect will be a slow regression to the mean. Many high flying specialists will make less than they have in the past, whereas many underpaid generalists who never had access to these multiplier effects will see their compensation increase.

If I had to put a number on the immediate and near-term future fair market value for anesthesiologist services (which I think is what most people reading this post are waiting for), I would guestimate that most employed anesthesiologists with 5 to 10 years of experience working full time and taking a reasonable amount of call will earn between $300,000 and $400,000.

As for job opportunities, I have not seen any compelling statistics that could be said to accurately describe a trend. As far as I know there are no data available about number of job openings, number of anesthesiologists seeking new positions, time to find a new job, or number of interviews required to find employment. I can describe the anecdotal experience of the northeastern US. In this region there are multiple groups and institutions advertising openings. I receive several emails each day from headhunters trying to fill locum tenens positions for understaffed institutions, and our practice has seen constant growth in the number of faculty for the past decade which only seems to be accelerating. So, my gut feeling is that there is no shortage of opportunity for anesthesiologists at present nor will there be in the foreseeable future, at least in this corner of the country.

Hope all this helps.
 
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Thank you, really appreciate you answering our questions. I am just curious as to what kind of attributes you try to identify during an interview process, which helps you decide if an applicant would be a successful resident.
 
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Thank you so much for doing this, @TempleChairman! Do you have any thoughts about medical students who have failed a class (or maybe for some even an entire year) in their pre-clinical years, but have otherwise done well since (e.g. good Step 1 scores)?
 
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Thank you, really appreciate you answering our questions. I am just curious as to what kind of attributes you try to identify during an interview process, which helps you decide if an applicant would be a successful resident.

Our interview process is designed to identify individuals that will succeed not only in our residency but also throughout a career in anesthesiology. The characteristics that we think are predictive of these endpoints include good communication skills, exceptional teamworking ability, perseverance, self discipline, self awareness, humility, and honesty (not necessarily in that order, but you get the idea).
 
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Thank you so much for doing this, @TempleChairman! Do you have any thoughts about medical students who have failed a class (or maybe for some even an entire year) in their pre-clinical years, but have otherwise done well since (e.g. good Step 1 scores)?

I don't think isolated periods of suboptimal academic performance are of great importance. Obviously there needs to be some evidence that a candidate has the requisite intellectual tools to accumulate and recall factual knowledge when they apply themselves. However, success in the field of anesthesiology will be determined at least as much by an individual's ability to adapt rapidly to changing conditions, work effectively and fluidly with the individuals around them, and drive themselves and the team to execute flawlessly under every circumstance. These characteristics are often only revealed when dealing with an area for which one feels some passion. If a medical student failed to feel much passion for cytology I do not think that would say much about their ability to succeed in any particular clinical field (except for maybe pathology).
 
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Thanks for your time! Do you weigh step 1 and 2 equally or is one more important to you?
 
Thanks for your time! Do you weigh step 1 and 2 equally or is one more important to you?

Step 1 and step 2 scores are weighted equally and are viewed in the context of the applicant's overall academic performance. They are considered equally valid potential measures of a candidate's ability to accumulate and interpret factual knowledge. However, we also look at the remainder of the applicant's academic record before reaching a conclusion.
 
Carbocation, I think the concepts encompassed by the terms Perioperative Surgical Home and Perioperative Medicine are exactly where the speciality of anesthesiology is heading. I do understand why the leaders of our specialty are promoting these terms in an attempt to disseminate the foundational principles amongst the 35,000 or so anesthesiologists across the country.

However, you should also understand that these terms have some political baggage attached to them as the result of the last 4 decades of “turf wars” that occurred in the US medical community. In the world of fee-for-service medicine the specialty that could “lay claim” to the most procedures or the greatest scope of expert opinion stood to gain financially. Thus, when the anesthesiology community promotes the idea of the Perioperative Surgical Home, there are both surgeons and internists that feel threatened by this and we have indeed seen negative commentary by the leadership of other specialty societies.

However, such feelings are misguided. I think the terms Perioperative Surgical Home and Perioperative Medicine both describe an organizational process that will provide the optimal care and overall experience from the patient perspective, rather than a new subspecialty of anesthesiology. This organizational process will be a team effort involving physicians and midlevel providers from various disciplines. The composition of these teams will vary from institution to institution. In many instances the team leadership will come from an anesthesiologist, but in every instance anesthesiologists who understand the organizational principals will need to be integrally involved.

As for salaries, predicting who will make what sort of income at some point in the future is very difficult. However, I think there are some generalities that can be applied.

During the past 30 years there were certain physicians who managed to generate enormous incomes as a result of what can be described as “multiplier effects”. It is difficult under a fee-for-service system for any single physician to generate enough work to provide a personal net income of $600,000 as an anesthesiologist, or $1,000,000 as an orthopedic surgeon. However, by employing many other providers (CRNAs, non-partner anesthesiologists) or by providing a large volume of profitable business to an institution with deep pockets (large numbers of inpatient admissions for a hospital) there were many specialists who did reach these income levels.

In the future, as hospital based specialties convert more and more to institutional employment, and as patients become clients of hospitals or health systems rather than individual “superstar” specialists, the opportunity to harvest these multiplier effects will dry up. The net effect will be a slow regression to the mean. Many high flying specialists will make less than they have in the past, whereas many underpaid generalists who never had access to these multiplier effects will see their compensation increase.

If I had to put a number on the immediate and near-term future fair market value for anesthesiologist services (which I think is what most people reading this post are waiting for), I would guestimate that most employed anesthesiologists with 5 to 10 years of experience working full time and taking a reasonable amount of call will earn between $300,000 and $400,000.

As for job opportunities, I have not seen any compelling statistics that could be said to accurately describe a trend. As far as I know there are no data available about number of job openings, number of anesthesiologists seeking new positions, time to find a new job, or number of interviews required to find employment. I can describe the anecdotal experience of the northeastern US. In this region there are multiple groups and institutions advertising openings. I receive several emails each day from headhunters trying to fill locum tenens positions for understaffed institutions, and our practice has seen constant growth in the number of faculty for the past decade which only seems to be accelerating. So, my gut feeling is that there is no shortage of opportunity for anesthesiologists at present nor will there be in the foreseeable future, at least in this corner of the country.

Hope all this helps.
Dr. Chairman:

What is your opinion on working for AMC vs. academic dept? Is there a future working for an AMC where you have no equity and unclear growth ladders. If you had a resident who didnt like academics would you say go work for an AMC like NAPA or sheridan or would you tell him to stay in "academics" because atleast he has a growth ladder here in case he/she develops an academic interest and also it looks better on paper for a doc to be affiliated with an academic dept? Your thoughts please..
 
Dr. Chairman:

What is your opinion on working for AMC vs. academic dept? Is there a future working for an AMC where you have no equity and unclear growth ladders. If you had a resident who didnt like academics would you say go work for an AMC like NAPA or sheridan or would you tell him to stay in "academics" because atleast he has a growth ladder here in case he/she develops an academic interest and also it looks better on paper for a doc to be affiliated with an academic dept? Your thoughts please..


Quickrecovery, when I am advising a resident, a faculty member, or just a friend about a job decision I usually start with all the “soft stuff” - where do you want to live, what does your spouse think, what stage are your kids at? The bottom line is that if someone is not happy where they are living, or their family is not happy for any reason, it doesn’t matter how great the job is - they won’t be there for long.

That said, if all other factors are equal and a candidate is looking at two similar jobs, one with an AMC and one at an academic center, I would probably at this point recommend the academic center for two reasons (full disclosure: I have spent significant time in both academics and as a full equity partner in a very successful private group, but have never worked for an AMC).

The first is that the academic center will usually have a greater vested interest in developing the career skills of the anesthesiologist. Academic department Chairs and medical school Deans are evaluated on how effective they are in promoting new competencies amongst their faculty - teaching new lecture series, developing new clinical skills or programs, participating in small trials or writing scholarly works. Thus, from day one a new faculty member should be being slotted into opportunities for professional growth. An AMC, on the other hand, is legitimately focused on running the most efficient business processes possible. This may or may not result in opportunities to develop new skill sets, and if so, usually in only a small subset of the professional staff. The end result is that after 5 years of practice, a new member of an academic department is much more likely to have aquired “value-added” skills than someone working for the same period for an AMC.

The second reason relates to the overall direction of the healthcare system. There are substantial arguments to be made that the AMC phenomenon has already seen its zenith and these corporations will quickly begin to fade from the scene. In the recent era of tightening financial margins and increasing scrutiny of “quality” metrics the AMCs had a strong value proposition for hospitals looking to iron out bumpy relationships with smaller independent anesthesia groups. The AMCs were large enough to guaruntee level staffing, could leverage market share to lower the subsidies demanded, and could speak the management language of dashboards and CQI (whether or not it was actually delivered). But the next decade is going to see a rapid shift away from fee-for-service towards bundled payments to healthcare systems. Once this occurs, the most rationale model is for hospitals to directly employ most of their medical professional staff rather than contract with a distant national management firm (also see response to carbocation1 above).

If the AMCs are going to experience decreasing market share and begin shedding professional staff I believe the value of time spent building good will with the corporate structure may simply be wasted. So, in summary, I would probably support your second choice above.
 
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Assuming I've got decent Step scores and clinical grades, will having xx,000 hours of experience as a respiratory therapist help me at all if I were to apply to anesthesia? I mean, I ran vents for years and can pretty much do it in my sleep, so I'd be quicker on the uptake in that regard.
 
i got a question for the temple guy. Why dont you guys ever pick up your damn phone.. You have a million ads on gaswork for this and than and when you call nobody picks the damn phone up. This may have changed since when i was calling was maybe 3-5 years ago. anyway start by answering that question
 
Assuming I've got decent Step scores and clinical grades, will having xx,000 hours of experience as a respiratory therapist help me at all if I were to apply to anesthesia? I mean, I ran vents for years and can pretty much do it in my sleep, so I'd be quicker on the uptake in that regard.

If you were applying to the Temple residency that sort of broader life experience would definitely be a positive factor.
 
i got a question for the temple guy. Why dont you guys ever pick up your damn phone.. You have a million ads on gaswork for this and than and when you call nobody picks the damn phone up. This may have changed since when i was calling was maybe 3-5 years ago. anyway start by answering that question

The Temple administrative support structures (such as receptionists to answer telephones) were notoriously bad up until the very recent past. Roughly 2 years ago the physician practice plan leadership launched a major customer service initiative with fairly impressive results. I suspect that most would find it much easier to get through now. (Although there are still times when I call the office and can't get an answer because everyone is tied up - you can never have enough help)
 
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The Temple administrative support structures (such as receptionists to answer telephones) were notoriously bad up until the very recent past. Roughly 2 years ago the physician practice plan leadership launched a major customer service initiative with fairly impressive results. I suspect that most would find it much easier to get through now. (Although there are still times when I call the office and can't get an answer because everyone is tied up - you can never have enough help)
I will put your theory to a robust test and get back to you. Are you a new chairman over there? Im not fond of any leadership in anesthesia. They have a "chocolate eclair" as their backbone.. You may be different. Perhaps. I will peruse your website and get back to you on that one.
 
Who actually wades through the hundreds (thousands?) of applications, and decides who gets an interview or not? I contacted a few programs I'm interested in but hadn't heard anything from...contacted the PD for 2 and the PC for 2. Wondering who actually has "the power" to review an app and grant an interview. Also...how likely is it for an applicant pulled from the wait list to actually have a shot of matching at that program?
 
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Apps go into 4 piles.

1. American Citizen elite American school
2. American citizen average med school or DO school
3. Foreign citizen elite foreign medical school
4. American citizen, average foreign school or Caribbean.

Sometimes elite students from pile 3 will jump over pile 2
 
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Who actually wades through the hundreds (thousands?) of applications, and decides who gets an interview or not? I contacted a few programs I'm interested in but hadn't heard anything from...contacted the PD for 2 and the PC for 2. Wondering who actually has "the power" to review an app and grant an interview. Also...how likely is it for an applicant pulled from the wait list to actually have a shot of matching at that program?

TinyRick, I suppose each program is a bit different. Certainly our process is nothing like the one described by Wiscoblue.

This year we screened roughly 850 applications by hand. We have 12 faculty who divide up the ERAS files and perform a preliminarily review of each applicant according to a structured scoring sheet. Neither nationality nor medical school is considered. The factors that are scored (with weightings) are USMLE Step 1 (10%), Dean’s Letter (10%), Reference Letters (20%), and “character indicators” (60%). I won’t reveal the exact “character indicators” we look for - they are our secret sauce. However, they are unambiguous identifiable aspects of a candidate’s life experiences that we feel correlate well with success in our specialty both during residency and afterwards.

After the scoring is complete we rank the candidates accordingly and begin extending invitations to interview. However, the interview schedule is very fluid and changes frequently as some individuals cancel and others are brought to our attention by trusted references as strong contenders. The interviews are key in confirming or refuting our initial impressions based on the ERAS file reviews and it is not uncommon to develop completely different rank orders by the time the interviews are completed. I don’t think that attending an interview after being on the wait-list has any negative implications. We simply can not interview everyone that applies and are very open to finding incredible candidates wherever they turn up.
 
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Certified registered nurse anesthetists play a vital role in our department and positions are available at Temple University Hospital. We have consistently been flexible in our recruitment efforts; often creating new full-time or part-time positions that fit the lifestyle(s) of our candidates. Sign-on bonuses have historically been offered.








Sincerely,

Gordon H. Morewood, MD
 
TinyRick, I suppose each program is a bit different. Certainly our process is nothing like the one described by Wiscoblue.

This year we screened roughly 850 applications by hand. We have 12 faculty who divide up the ERAS files and perform a preliminarily review of each applicant according to a structured scoring sheet. Neither nationality nor medical school is considered. The factors that are scored (with weightings) are USMLE Step 1 (10%), Dean’s Letter (10%), Reference Letters (20%), and “character indicators” (60%). I won’t reveal the exact “character indicators” we look for - they are our secret sauce. However, they are unambiguous identifiable aspects of a candidate’s life experiences that we feel correlate well with success in our specialty both during residency and afterwards.

After the scoring is complete we rank the candidates accordingly and begin extending invitations to interview. However, the interview schedule is very fluid and changes frequently as some individuals cancel and others are brought to our attention by trusted references as strong contenders. The interviews are key in confirming or refuting our initial impressions based on the ERAS file reviews and it is not uncommon to develop completely different rank orders by the time the interviews are completed. I don’t think that attending an interview after being on the wait-list has any negative implications. We simply can not interview everyone that applies and are very open to finding incredible candidates wherever they turn up.

That was extremely helpful, thank you. The process is so ambiguous to an outsider; very enlightening to see how you approach such a huge volume of applications. I'm surprised and pleased to see the weight you give "character indicators"...nice to see that you acknowledge that much more than a test score is needed to judge the fit and level of likely success of a candidate.
 
That was extremely helpful, thank you. The process is so ambiguous to an outsider; very enlightening to see how you approach such a huge volume of applications. I'm surprised and pleased to see the weight you give "character indicators"...nice to see that you acknowledge that much more than a test score is needed to judge the fit and level of likely success of a candidate.

I wouldn't read to much into one program. I'm sure quite a few others (upper 1/4) weigh the USMLE scores much greater that Temple does. The statistics clearly back up my statement that scores matter on the national level much more than any "secret sauce" at Temple. Of course, Temple may not be the only program to devalue the USLME especially when they have a hard time finding top applicants.
 
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I wouldn't read to much into one program. I'm sure quite a few others (upper 1/4) weigh the USMLE scores much greater that Temple does. The statistics clearly back up my statement that scores matter on the national level much more than any "secret sauce" at Temple. Of course, Temple may not be the only program to devalue the USLME especially when they have a hard time finding top applicants.

ouch
 
I wouldn't read to much into one program. I'm sure quite a few others (upper 1/4) weigh the USMLE scores much greater that Temple does. The statistics clearly back up my statement that scores matter on the national level much more than any "secret sauce" at Temple. Of course, Temple may not be the only program to devalue the USLME especially when they have a hard time finding top applicants.

Blademda, your point is well taken - every program has a somewhat different approach as to how they identify desirable applicants, although I think the overall message of your post is grossly oversimplified and does a disservice to those medical students reading this thread. As for our applicant pool, your comment piqued my interest because we simply had never analyzed it by USMLE scores so I did not know the answer. As a result, I dragged out the excel spreadsheet this morning and performed some number crunching.

Of the 880 applications Temple screened this year, the range of USMLE scores was from a low of 184 to a high of 263. The mean was 226 with a standard deviation of 16. If you limited the analysis to only the 100 applicants with the top USMLE scores, the range was 245 to 263 with a mean of 251 and a standard deviation of 5.6.

Interestingly (and completely unknown to me prior to this morning), of those 100 candidates with the top USMLE scores we offered interviews to only 25.

There is an important foundational concept at work here which I think is very poorly understood by medical students and recent graduates. Until your last day of medical school your entire value system (as least with regard to your career) tends to revolve around scores assigned on tests and standardized examinations. The MCATs, GPAs, USMLEs, etc define, to a significant degree, the opportunities that will be available to you.

The first day of your career as a licensed physician a paradigm shift occurs. Your value to a group or institution is almost entirely based on your ability to complete the technical, cognitive, and organizational work in front of you. You must be able to effectively problem-solve in real time (“real” problems in a real-world context, not just hypothetical academic medical questions), you must be able to constructively teamwork with the other individuals around you, and you must be able to address the most fundamental desire of patients and their families - the need to “feel better”. Communication, negotiation, emotional intelligence, the ability to multitask, and an intrinsic understanding of how to promote the highest possible performance in others are what create the high value physicians that both institutions and private groups will do anything to attract and retain.

Of the 150 or so specialists that I interact with regularly, there is not a single one that I know their medical school, residency location, or board scores. It simply is not relevant. The only things I care about are: are they pleasant and positive to interact with, can they do their job, and are they a positive influence on the system and, as a result, my ability to do my job?

Which brings me back to the USMLE scores. If you review the specific skills listed above required for career success in medicine / anesthesiology, there is little or no reason to think that a multiple choice examination covering basic science material after two years of medical school has any predictive value whatsoever. I believe that many larger programs rely so heavily on USMLE scores simply because it is easy to do so, and too much work to use more sophisticated selection systems. We devalue the USMLE not because we don’t have access to high scoring candidates, it simply is not relevant in our drive to identify the future stars in our specialty.

To illustrate, imagine a choice of two candidates. The first moved directly from high school to undergraduate to medical school achieving top academic grades the entire time but gaining no other experience - USMLE step 1 score 270. The second spent 4 years in the marine core, worked for an insurance company for 2 years after that while pursuing an MBA, then attended medical school - USMLE step 1 score 200. In reality we would spend significant time digging deeper into both candidates, but based solely on the facts listed above it has been my experience over the past two decades that the second candidate would be significantly more likely to have an impact on the medical system in which they go on to work and to be identified as a leader.

The end result of our “secret sauce” is that our residents are routinely selected for top fellowships and are actively pursued by private practices that have previously employed our graduates. In contrast, there are “top name” (from a medical student perspective) residencies that our local private practice groups will not hire from simply because their past experience has been that their trainees can’t do the job.

I offer all of this information simply for perspective. As medical students ponder their future after graduation it is challenging but essential that they begin to shift their focus regarding what is important. Regardless of which training program they select, once they achieve technical competence their future success as anesthesiologists will depend almost entirely on skills and personal characteristics that are not tested by the USMLE, or even the ABA Board Exams. After all, Boards are a pass / fail system. No one is going to ask you what you scored.
 
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Blademda, your point is well taken - every program has a somewhat different approach as to how they identify desirable applicants, although I think the overall message of your post is grossly oversimplified and does a disservice to those medical students reading this thread. As for our applicant pool, your comment piqued my interest because we simply had never analyzed it by USMLE scores so I did not know the answer. As a result, I dragged out the excel spreadsheet this morning and performed some number crunching.

Of the 880 applications Temple screened this year, the range of USMLE scores was from a low of 184 to a high of 263. The mean was 226 with a standard deviation of 16. If you limited the analysis to only the 100 applicants with the top USMLE scores, the range was 245 to 263 with a mean of 251 and a standard deviation of 5.6.

Interestingly (and completely unknown to me prior to this morning), of those 100 candidates with the top USMLE scores we offered interviews to only 25.

There is an important foundational concept at work here which I think is very poorly understood by medical students and recent graduates. Until your last day of medical school your entire value system (as least with regard to your career) tends to revolve around scores assigned on tests and standardized examinations. The MCATs, GPAs, USMLEs, etc define, to a significant degree, the opportunities that will be available to you.

The first day of your career as a licensed physician a paradigm shift occurs. Your value to a group or institution is almost entirely based on your ability to complete the technical, cognitive, and organizational work in front of you. You must be able to effectively problem-solve in real time (“real” problems in a real-world context, not just hypothetical academic medical questions), you must be able to constructively teamwork with the other individuals around you, and you must be able to address the most fundamental desire of patients and their families - the need to “feel better”. Communication, negotiation, emotional intelligence, the ability to multitask, and an intrinsic understanding of how to promote the highest possible performance in others are what create the high value physicians that both institutions and private groups will do anything to attract and retain.

Of the 150 or so specialists that I interact with regularly, there is not a single one that I know their medical school, residency location, or board scores. It simply is not relevant. The only things I care about are: are they pleasant and positive to interact with, can they do their job, and are they a positive influence on the system and, as a result, my ability to do my job?

Which brings me back to the USMLE scores. If you review the specific skills listed above required for career success in medicine / anesthesiology, there is little or no reason to think that a multiple choice examination covering basic science material after two years of medical school has any predictive value whatsoever. I believe that many larger programs rely so heavily on USMLE scores simply because it is easy to do so, and too much work to use more sophisticated selection systems. We devalue the USMLE not because we don’t have access to high scoring candidates, it simply is not relevant in our drive to identify the future stars in our specialty.

To illustrate, imagine a choice of two candidates. The first moved directly from high school to undergraduate to medical school achieving top academic grades the entire time but gaining no other experience - USMLE step 1 score 270. The second spent 4 years in the marine core, worked for an insurance company for 2 years after that while pursuing an MBA, then attended medical school - USMLE step 1 score 200. In reality we would spend significant time digging deeper into both candidates, but based solely on the facts listed above it has been my experience over the past two decades that the second candidate would be significantly more likely to have an impact on the medical system in which they go on to work and to be identified as a leader.

The end result of our “secret sauce” is that our residents are routinely selected for top fellowships and are actively pursued by private practices that have previously employed our graduates. In contrast, there are “top name” (from a medical student perspective) residencies that our local private practice groups will not hire from simply because their past experience has been that their trainees can’t do the job.

I offer all of this information simply for perspective. As medical students ponder their future after graduation it is challenging but essential that they begin to shift their focus regarding what is important. Regardless of which training program they select, once they achieve technical competence their future success as anesthesiologists will depend almost entirely on skills and personal characteristics that are not tested by the USMLE, or even the ABA Board Exams. After all, Boards are a pass / fail system. No one is going to ask you what you scored.
Excellent post chairman. I have always maintained that we are mis using the usmle, mcat score etc etc because of what you said above. Your score on the usmle has as much to do with your success as a real world physician as how high you can jump or how much you benchpress but we continue to use these metrics and wonder where we go wrong.

Elminate scores from usmle, mcat and use interview skills, narrative evaluations as your benchmark. If programs continue to use usmle scores they should also ask physical performance measures as well. How many pushups can you do in one minute? How long can you stand on your feet without dropping? etc etc..

good post chairman..
 
FWIW, the interview/ranking process is similar in some rads programs to what you describe, especially in terms of the "secret sauce". Step 1 obssessed programs occasionally get hit with surprises they were not expecting, i.e. a malignant, arrogant, or nonfunctional Step 1 superstar. They then have two options at that point: (1) reassess their interview and rank list criteria, or (2) deny the problem or consider it a "fluke" that happens fairly regularly. Unfortunately, many programs I know go for (2). I congratulate you on devaluing Step 1 in favor of interpersonal skills.
 
Thank you for answering our questions.

When deciding to whom to offer interviews, how do you allocate appropriate numbers of interviews to unlikely matches (quite high USMLE scores, polished applications, good "secret sauce") who are applying to 30+ programs but are applying to Temple as more of a back-up option (residency applicants can be quite paranoid, and they try to apply to as many programs as possible to help them feel secure) versus likely matches (good scores, good "secret sauce", average USMLE scores for your typical class)?

I have seen a phenomenon where some residencies offer most of their interviews to the most-competitive applicants, who are likely not going to match to their program. Is this something you are very careful about to ensure a very good matching class?
 
Nice posts templechairman

Now I'm wondering what special sauce I'm missing from my sesame seed bun
 
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On the pain interview trail this year, someone mentioned that Temple's Anesthesia program is on probation. Is this true?
 
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Thank you for your time and effort, TempleChairman.
You've mentioned the following criterion for getting through the initial screening process: "The applicant must have attended a medical school acceptable to the ACGME (domestic or foreign)". What does that mean in terms of the probability of foreign medical graduates matching into your program? what are your views regarding medical education outside of North America (when considering an applicant) and how big of a role does visa status (H/J) play in your program?
 
Thank you for answering our questions.

When deciding to whom to offer interviews, how do you allocate appropriate numbers of interviews to unlikely matches (quite high USMLE scores, polished applications, good "secret sauce") who are applying to 30+ programs but are applying to Temple as more of a back-up option (residency applicants can be quite paranoid, and they try to apply to as many programs as possible to help them feel secure) versus likely matches (good scores, good "secret sauce", average USMLE scores for your typical class)?

I have seen a phenomenon where some residencies offer most of their interviews to the most-competitive applicants, who are likely not going to match to their program. Is this something you are very careful about to ensure a very good matching class?

Chfo, what you are referring to (perhaps you are familiar with this, perhaps not) is the branch of decision making referred to as game theory.

Most management decisions are exercises in optimizing outcomes based on fixed external constraints. In the 1940s mathematicians began to describe a system of decision optimization based on a series of probabilities of outcomes in a variable external constraint (another individual’s decisions) which in turn were dependent on the likelihood of the first internal decision. Game theory has grown into a major field of academic inquiry in both mathematics and management science.

Needless to say, this type of response is far too sophisticated for our resources. We simply attempt to determine who would be the best match for our program and rank the individuals accordingly. My own feeling is that each program’s selection process is sufficiently different (see post to baldemda above) that we are not simply all chasing the same candidates (except for perhaps those that use a “90% USMLE step 1” approach).
 
On the pain interview trail this year, someone mentioned that Temple's Anesthesia program is on probation. Is this true?


During our program’s RRC review last spring the site-visitors noted 12 issues that they felt needed to be addressed before unconditional continuing accreditation could be granted. The majority of these had to do with the administrative organization of the residency program oversight: who was performing key roles, how oversight committees functioned, how cases and evaluations were being logged. The other citations related directly or indirectly to staffing levels – they felt that insufficient faculty and CRNAs were available to support the required atmosphere and scholarly work that should be associated with a residency program, and to protect residents from excessive service requirements at times compromising purely educational activities.

I believe these were all completely valid criticisms. Temple, like most other academic medical centers across the country, has been under external financial pressure for the past five years as the landscape of the US healthcare system has evolved. This financial pressure, combined with dramatic recent internal growth, had lead to a sharp increase in the volume of clinical work being performed without an adequate increase in the resources available to the anesthesiology department.

The benefit of the RRC’s report has been a refocusing of the health system’s dedication to and support of the residency program. During the 12 months from July 2015 through July 2016 the operating budget for the department has been increased 27% (an unheard of amount in the current climate) - the vast majority of which will be spent on increasing faculty and CRNA numbers. The administrative issues have been largely conquered by the incredible team lead by our inexhaustible new program director. Thus, we anticipate that unconditional accreditation will be restored in short order.

Although I am not sure it is necessary, I know the faculty and residents would want me to explicitly mention here that the probationary status had nothing to do with the quality of the clinical training the residents received, the high caliber of which has always been the hallmark of the program.
 
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Thank you for your time and effort, TempleChairman.
You've mentioned the following criterion for getting through the initial screening process: "The applicant must have attended a medical school acceptable to the ACGME (domestic or foreign)". What does that mean in terms of the probability of foreign medical graduates matching into your program? what are your views regarding medical education outside of North America (when considering an applicant) and how big of a role does visa status (H/J) play in your program?

Rac65, provided that the candidate has legal status to work in the US via citizenship, permanent residency, or an appropriate visa this specific factor does not impact our scoring of individual candidates. When considering a candidate who seems otherwise highly qualified but attended a foreign medical school with which our faculty members are not familiar, we reach out to our extended network of colleagues to find an individual who trained in the country in question. This simple process usually provides the assurance we need regarding the adequacy of the foundational medical education provided.

And, of course, the institution must be one that has achieved the requisite accreditations to achieve standing with the ACGME and the Pennsylvania State Board of Medicine.

Over the past decade we have had truly exceptional trainees pass through the residency program whose medical degrees were obtained in Columbia, Venezuela, and India (off the top of my head). As mentioned earlier in this thread, our primary focus at all times is finding the most outstanding candidates who will move on to lead in our specialty, wherever those individuals might be found.
 
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Thanks for your time TempleChairman it's good to have someone answer questions who has a solid background in the process. Do program directors have access to percentiles for how many procedures there residents do compared to others? I've heard PDs say they're in the top percentile for hearts/trauma/open neuro/regional. Do you get numbers for specific residents, like 'this resident did the most cardiac procedures this year in the U.S. out of all residents' (I've heard this)
 
Which anesthedia fellowships have the best career outlook and which do you find to be the most practical?
 
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If you had a choice of going to a top 25 program or a program that wasn't in the top 25 but you felt like would be a perfect fit...which program would you rank higher?
 
Thank you dr. chairman:

As a fellow academic at a mid tier program I commend you on taking the initiative to answer these important questions. Too often we in medicine do not mentor our young about the true nature of anesthesia as a career and as a business. I wish there were more folks like yourself who so generously would share their knowledge. I am very happy at my host institution but if I ever decide there is time for a change I will look at Temple more favorably seeing that it is run by individuals like yourself.
 
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Thanks for your time TempleChairman it's good to have someone answer questions who has a solid background in the process. Do program directors have access to percentiles for how many procedures there residents do compared to others? I've heard PDs say they're in the top percentile for hearts/trauma/open neuro/regional. Do you get numbers for specific residents, like 'this resident did the most cardiac procedures this year in the U.S. out of all residents' (I've heard this)

Maverikk, I needed to consult with our program direct before I could answer your post. Neither of us are aware of any avenue whereby the data entered in the resident case logs during training are tabulated or made public by the ACGME. In fact, its seems to be a common practice at many programs for the residents to stop entering cases once they have reached their required minimum numbers in a given category. Therefore, even if these numbers were tabulated and released on a national basis it seems unlikely that they would have much validity.

As a result, I would suspect that statements such as those you have listed above have no solid foundation.
 
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Which anesthedia fellowships have the best career outlook and which do you find to be the most practical?

ToKingdomCome, I have given this some considerable thought and I can not produce any concrete reasons to predict that any one particular type of fellowship will be more employable or useful in the future than any of the others. You can always find someone who is quite happy to make a sweeping statement that “all of those ‘X’ fellows will be unemployable in 5 years”, but such comments are rarely ever based on solid data or proven correct over time.

Over the past decade my advice regarding fellowship has remained fairly constant - if a resident identifies an area of clinical anesthesiology that they particularly enjoy or find especially interesting, then they should consider a fellowship in that area. However, it is almost never worth doing a fellowship simply to make yourself more marketable. The problem with pursing a fellowship to secure a job is that the subspecialty job that happens to be available after training is complete may not be in a location, or in an institution, or carry a salary that you find agreeable. And the perfect job in the perfect hospital in the perfect town may be available but not need the fellowship you just completed.

In the last year or two I have begun to modify this position slightly. As healthcare institutions move more toward system-based care there is a growing need for individuals with subspecialty training or experience to participate in the managerial level decisions required to shape efficient and effective workflows. This does increase the value of most fellowships. At Temple we are currently recruiting for several positions including individuals with fellowship training in critical care, obstetrical anesthesia, regional anesthesia, and cardiac anesthesia. So I do see a slight but definite increase in the utility of fellowship training in the future, but can not identify one program that holds more promise than any other necessarily.
 
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If you had a choice of going to a top 25 program or a program that wasn't in the top 25 but you felt like would be a perfect fit...which program would you rank higher?

No question - the perfect fit.

After three years in a program that is a perfect fit you will (hopefully) be engaged, enthusiastic, show leadership skills and be well known to all of the faculty.

After three years in a “top 25” program where the culture wasn’t completely compatible with your own personality, you may have survived but are unlikely to have impressed people nearly as much on a daily basis with your future potential to be a high impact member of the health care team.

When you send out your resume at the end of your training to find a job or a fellowship position, the individual who receives that resume is going to first look closely at the institution where you trained but probably not for the reason that you think. If they have an open position and you have the requisite qualifications to fill it, their first step is usually to figure out who they know in the institution where you trained so that they can make one quick phone call to obtain a concise summary of your potential. You won’t know who that faculty member will be, but her/his assessment will have a far greater impact on the jobs you are offered than any factor on your resume including the specific identity of your training institution.

Therefore, your optimal overall career strategy is to position yourself in an environment (as best you can) where you will feel comfortable enough to impress the heck out of everyone that works with you every day.
 
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